~1r 


COLUMBIA  LIBRARIES  OFFS1TE 

HEALTH  SCIENCES  STANDARD 


Columbia  ®ntoergttj> 

intijeCttpirfltogtfrk 

College  of  $f)2>£i«ang  anb  gmrgeong 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/administrativecoOObigg 


226  L-1907 


20(17,  'OP,  5,000  (P) 


The  Department  of  Health,  City 
of  New  York,  Sixth  Avenue  and 
Fifty-fifth  Street — The  Adminis- 
trative   Control    of    Tuberculosis. 


1907 


14$ 
Ho1 


THE  ADMINISTRATIVE  CONTROL  OF 
TUBERCULOSIS. 

BY  HERMANN  M.  BIGGS,  M.  D. 
Chief  Medical  Officer  Department  of  Health,  City  of  New  York 


When  we  consider  the  transcendent  importance  to  the 
human  race  of  the  observations  of  Koch  on  the  etiology  of 
tuberculosis,  and  the  completeness  of  his  demonstration  of 
the  communicable  and  preventable  character  of  the  disease, 
it  seems  difficult  to  understand  the  limited  extent  of  the  san- 
itary procedures  since  adopted  and  enforced  for  its  restric- 
tion. The  imperative  demand  for  the  enforcement  of  com- 
prehensive measures  for  the  prevention  of  tuberculosis 
should  have  been  as  evident  to  sanitarians  twenty  years  ago 
as  it  is  today.  No  facts  have  been  added  to  our  knowledge 
within  this  period  which  are  really  essential  to  the  intelligent 
sanitary  surveillance  of  this  disease.  The  universal  preva- 
lence of  the  disease,  its  infectious  and  communicable  charac- 
ter, its  preventability  and  curability,  all  of  these  facts — the 
important  ones  bearing  on  the  administrative  control — are 
not  of  recent  discovery.  They  have  not  been  developed  by 
the  agitation  of  the  past  few  years,  but  were  as  manifest  to 
the  student  of  this  subject  fifteen  or  twenty  years  ago  as 
they  are  now.  Very  slowly  has  a  partial  comprehension  of  the 
tremendous  significance  of  these  simple  well-known  facts 
forced  itself  on  the  minds  of  the  medical  profession,  the  san- 
itary and  civil  authorities,  and  the  people.  Even  now, 
only  here  and  there  throughout  the  civilized  world  have 
measures  been  put  into  effect  looking  to  the  administrative 
control  of  tuberculosis.  Notwithstanding  all  that  has  been 
said  and  written,  notwithstanding  the  popular  education  and 
agitation,  notwithstanding  the  formation  of  antituber- 
culosis societies  and  antituberculosis  leagues,  notwith- 
standing the  organization  of  many  associations  for  the  erec- 
tion of  sanitoria,  and  the  foundation  of  institutions  for  the 
study  of  tuberculosis,  notwithstanding  the  measures  adopted 


for  the  prevention  of  the  disease  in  animals,  still  only  a  very 
small  percentage  of  the  governmental  municipal  and  State 
sanitary  authorities  of  this  country,  Great  Britain  and  the 
Continent  have  adopted  provisions  which  can  be  regarded 
as  in  any  way  comprehensive,  or  effective  in  dealing  with 
this  disease. 

If  we  seek  for  an  adequate  explanation  for  this  attitude, 
it  is  not  after  all  difficult  to  find.  In  speaking  of  this  matter 
somes  years  ago,  Koch  said  in  substance  to  the  writer,  "the 
adoption  in  Germany  of  such  measures  as  are  already  in 
force  in  New  York  City  will  not  be  possible  until  the  genera- 
tion of  medical  men  now  in  control  have  passed  away.  Not 
until  a  younger  generation  has  appeared,  which  has  had  a 
different  scientific  training,  and  holds  views  more  in  har- 
mony with  the  known  facts  regarding  the  etiology  of  tuber- 
culosis, will  it  be  possible  in  my  opinion  to  bring  about  an 
intelligent  supervision  of  this  disease." 

The  idea  has  been  so  firmly  fixed  in  the  minds  of  the  au- 
thorities and  of  the  medical  profession,  that  administrative 
control  applies  only  to  the  more  readily  communicable  acute 
diseases,  like  smallpox,  scarlet  fever,  diphtheria,  etc.,  that  the 
inclusion  of  tuberculosis  with  these  diseases  has  seemed  to 
them  impracticable,  and  the  enactment  of  suitable  legisla- 
tion conferring  power  on  the  authorities  to  deal  with  this 
disease  in  another  way  has  either  not  been  considered  or  has 
been  regarded  as  impossible.  In  only  a  few  instances  have 
effective  measures  been  adopted,  and  in  these  instances,  as 
was  the  case  in  New  York,  the  power  has  usually  rested 
with  the  sanitary  authorities  themselves  to  determine  what 
diseases  should  come  under  their  surveillance,  and  under 
what  conditions. 

Notification  is  a  necessary  preliminary  to  any  plan  of 
supervision,  and  yet  some  years  ago  a  special  commission 
of  the  Academy  of  Medicine  of  Paris  reported  against  a 
proposition  to  place  tuberculosis  in  the  class  of  notifiable  dis- 
eases. Two  principal  reasons  were  advanced  against  the 
proposition :  First  it  was  pointed  out  that  notification  in- 
volved the  divulging  of  a  medical  secret,  which  would  be 
harmful  to  the  patient  (this  applies  of  course  with  equal 
force  to  the  diseases  usually  called  contagious)  ;  and  it  was 


01 01 

<;o«i 

1 

snoi 

£061 

nor,  i 

/ 

f 

T 

COfil 

• 

/ 

•  i 

} 

fOCT 

i 

< 

' 

< 

8061 

) 

> 

r.OGT 

V 

) 

I 

/ 

ICG1 

f 

4 

/ 

1 

/ 

OOfil 

K 

j 

i 

i 

GO  8 1 

V 

^ 

' 

> 

X 

8G81 

> 

J 

z 

1681 

j 

o 

06SI 

LL 

m 

9GRT 

< 

( 

HI 

T 

fG8T 

> 

SCSI 

/ 

h- 

SG81 

ID 

D 

1681 

i 

k 

tiJJ 

3 

Z 

0681 

■> 

/ 

< 

6881 

/ 

HI 

h- 

1- 

-Q 

LU 

L 

u 
r 

z 

< 

8S8I 

i 

' 

< 

< 

rr 

"5 

< 

C_ 

1881 

' 

T 

I 

X 

I 

r- 

0881 

\ 

< 

f- 
<• 

C 

< 

r- 
< 

< 

X 

2881 

LU 

n 

LU 

n 

) 

LU 
Q 

LU 

n 

f88I 

_i 

; 

CO 

> 

_l 

CO 

< 

S8ST 

~" 

i 

oc 

< 

/ 

to 

LU 

< 

QC 

c 

n 

E- 

2 

S8S1 

,«- 

z 

/ 

h- 

QC 
LU 

- 

f 

1881 

LLl 

1 

] 

3 

c 

L 
L 

0881 

V 

\ 

r- 

6281 

> 

LU 

8181 

< 

< 

O 

1181 

> 

0181 

i 

/ 

BIST 

i 

U81 

/ 

i 

8181 

> 

/ 

S181 

f 

I1SI 

l- 

— 

7 

\ 

0181 

4 

( 

\ 

S 

6081 

s 

k 

s 

n 

' 

« 

M 

O 

B 

^ 

SO 

"3 

-r 

c> 

3 

^3 

30 

e* 

- 

5 

o 

TO 

DO 

ei 

ITS 

si 

Vi 

->' 

71 

o 

=s 

ao 

in 

N 

furthermore  insisted  that  as  the  public  did  not  regard  tuber- 
culosis as  being  contagious,  or  in  the  same  class  with  the 
contagious  diseases,  but  considered  the  disease  hereditary, 
the  public  would  not  accept  such  a  legal  enactment  without 
protest  and  resistance.  The  second  reason  was  regarded  as 
more  important  and  was  in  effect  that  in  a  family  unwilling 
to  follow  instructions  sanitary  restrictions  would  be  impos- 
sible, as  an  almost  continuous  intervention  would  be  required 
on  the  part  of  the  sanitary  officers  for  months  and  years. 
The  only  efficient  alternative  in  such  cases,  it  was  pointed 
out,  would  be  the  consignment  of  the  consumptive  to  a  hos- 
pital, a  practice  followed  in  Norway.  The  Commission  con- 
cluded that  compulsory  notification  must  not  be  considered, 
at  least  at  that  time. 

Sir  Richard  Thorne,  the  Medical  Officer  to  the  Local 
Government  Board  of  Great  Britain,  in  the  Harben  lecture 
in  1898  on  "The  Administrative  Control  of  Tuberculosis," 
after  a  careful  consideration  of  the  various  problems  pre- 
sented under  the  English  law  relating  to  infectious  diseases, 
pronounced  definitely  against  this  proposition,  on  the  ground 
that  the  hardship  to  the  individual,  which  would  follow  notifi- 
cation and  the  enforcement  of  proper  regulations,  would  be 
so  great  as  to  render  this  measure  unjustifiable.  In  the 
same  year  the  Academy  of  Medicine  of  New  York,  through 
a  special  committee  appointed  to  consider  the  regulations, 
which  had  then  been  adopted  by  the  Department  of  Health 
of  New  York  City  regarding  notification,  declared  it  as  its 
opinion  that  the  procedure  was  at  that  time  inexpedient  and 
inadvisable.  Every  important  medical  society  in  New  York 
City  then  expressed  even  more  strongly  than  the  committee 
of  the  Academy  the  opinion  that  the  action  of  the  Health 
Board  was  unwise  and  unwarranted. 

In  the  action  of  these  and  other  societies  and  commis- 
sions, and  in  the  opinions  expressed  by  various  authorities 
throughout  the  world,  it  has  always  been  evident  that  they 
have  been  influenced  by  precedents  as  to  the  functions  of  the 
sanitary  authorities,  and  have  felt  very  strongly  the  strik- 
ing difference  between  tuberculosis  and  the  diseases,  which 
had  previously  been  subject  to  sanitary  control.  It  has  often 
been  pointed  out  that  the  so-called  contagious  diseases  are 


acute,  and  the  whole  history  of  even  the  most  protracted  case 
is  comprised  within  a  period  of  a  few  weeks,  or  at  most  a 
few  months,  whereas  with  tuberculosis,  the  infectious  period 
usually  extends  not  simply  over  a  few  months,  but  more  fre- 
quently over  several  years,  and  it  may  comprise  half  a  life- 
time. 

The  contagious  diseases  usually  entirely  incapacitate  the 
individual,  during-  the  early  period  at  least,  and  the  dangers 
of  the  transmission  of  the  infection  are  so  great  and  the 
evidence  of  it  so  immediate,  that  no  questions  can  properly 
be  raised  as  to  the  justification  for  proper  isolation  and  su- 
pervision. On  the  contrary,  all  authorities  agree  that  under 
proper  conditions  the  consumptive  is  not  necessarily  a  source 
of  danger,  even  to  his  most  intimate  associates.  He  may  be 
able  to  pursue  his  usual  avocation  for  years.  The  danger 
of  the  transmission  of  the  disease  is  much  less  evident,  and 
the  source  of  infection  is  much  more  difficult  to  trace. 

The  consideration  of  these  and  other  important  points  of 
difference  between  tuberculosis  and  the  contagious  diseases 
has  dominated  the  situation.  It  has  seemed  difficult  for  the 
medical  or  lay  sanitary  authorities  to  understand,  that  with 
the  new  knowledge  afforded  by  the  observation  of  Koch  and 
others  an  entirely  different  sanitary  problem  was  presented 
for  their  consideration,  and  that  for  its  solution  new  methods 
must  be  adopted.  Very  gradually  comprehension  of  this 
simple  and  apparently  quite  self-evident  fact  has  forced  itself 
upon  them.  It  may  be  said,  I  think,  to  be  now  an  almost 
universally  accepted  fact  that  some  kind  of  action  or  super: 
vision  is  justifiable  and  necessary,  and  the  only  difference  of 
opinion  is  as  to  the  extent  of  the  measures  which  should  be 
adopted  and  as  to  the  manner  of  their  enforcement. 

It  is  my  desire  in  this  address  to  present  for  your  consid- 
eration, what  it  seems  to  me  these  procedures  should  be,  and 
also  in  part  what  they  are  now  in  New  York  City.  I  may 
say  in  passing  that  so  long  ago  as  1887  I  had  the  privilege, 
in  conjunction  with  the  other  consulting  pathologists  to  the 
Department  of  Health  of  New  York  City,  of  advocating  the 
adoption  in  New  York  of  measures  almost  as  comprehensive 
as  those  now  in  force,  but  it  was  so  evident  at  that  time, 
that  neither  the  medical  profession  nor  the  people  of  the  City 


would  approve  these  measures,  that  the  Board  of  Health 
felt  their  immediate  adoption  in  toto  was  inadvisable. 

What  measures  then  does  the  efficient  administrative  con- 
trol of  tuberculosis  require? 

I.  The  compulsory  notification  and  registration  of  all 
cases  is  essential.  The  fundamental  importance  of  this 
measure  is  so  evident  that  its  consideration  seems  hardly 
necessary.  It  must  of  course  appear  at  once  that  unless 
there  is  a  system  of  compulsory  notification  and  registration, 
the  enforcement  of  any  uniform  measures  for  prevention  is 
impossible.  Practical  experience  with  this  procedure  has 
made  it  perfectly  clear  that  the  objections  which  have  been 
urged  against  it  are  without  force  or  foundation. 

In  New  York  City  in  1893  a  system  of  partially  voluntary 
and  partially  compulsory  notification  was  adopted.  Public 
institutions  were  required  to  report  cases  coming  under 
their  supervision;  private  physicians  were  requested  to  do 
this.  Under  this  provision  the  Department  of  Health  car- 
ried on  this  work  for  three  and  a  half  years,  and  then  adopt- 
ed in  1897  regulations  requiring  the  notification  of  all  cases. 
For  a  number  of  years,  while  continuous  pressure  was 
brought  to  enforce  this  provision,  it  was  not  strictly  en- 
forced, although  more  and  more  complete  compliance  with 
its  requirements  was  each  year  attained. 

It  has  already  been  said  that  as  tuberculosis  radically  dif- 
fers from  the  more  readily  communicable  diseases  usually 
called  contagious,  so  the  measures  for  the  sanitary  super- 
vision of  tuberculosis  must  differ  from  the  measures  adopt- 
ed in  this  class  of  diseases.  This  should  be  the  attitude  of 
the  health  authorities  always,  in  the  enactment  and  enforce- 
ment of  all  regulations.  The  information  contained  in  the 
reports  of  cases  should  be  regarded  as  confidential  informa- 
tion, and  action  should  only  be  taken  by  the  authorities  in 
those  instances  where  the  conditions  require  it. 

The  notification  of  a  case  of  tuberculosis  does  not  re- 
quire any  action  on  the  part  of  the  authorities,  if  it  seems 
reasonable  to  assume  that  such  action  is  unnecessary.  The 
very  fact  that  tuberculosis  is  notified  by  the  attending  phy- 
sician as  a  communicable  disease  has  the  greatest  educa- 
tional value,  and  justifies  the  assumption  in  those  instances, 


£-5 


«  jy 


3 

u 

o 

u 

X 

3 

H 

T3 

:> 

rt 

« 

o 

F,-£ 

O 

■a 

H  « 


J3rC 


o - 

o  g 


I  CO  m  \0    CO  ■<*■  ( 


iO^h  o  CO  \o  t-  * 


O  «  NO    SfONO 


«    N   «    W    N    N    C* 


)  H    tJ-VO    -tMM  lOCOO    O^OCO 


«  vo  onno  t->.\o  in  m  \o  iohco  oco  0  ir>  m  0  h\o  n 
■"*■  0   OnCO   OM^Vhom    rot-i   On  On  0    o  co  no   t"»  i--.no   C- 

^■i-roforomronmcofON  «  ro  ro  cm  w  w  «  «  n 

On  <N    On  «    t^M   tri  0  NO    ■<*-  -«h  fONO   HmiOKt^OMM 
O  en  (t,  r^oo  m  a  fo  n  m  co  o  ^co  0  -*■  m  mo  o  t^. 

u-j\0  en  in  ^-\o  mvotsroiHOOOM 

0    OCO    M0O00 

VO    t^-00    O^O    H    M    f  *  irjvo    txoo    On  0    H    N    en  •<*■  f*;\D 

ooooooco  er\0>o>oooooNcno>o  0  Q  0  o  0  o 
oooococococooocoooaocooocooo  o>  on  cr<  o>  o\  C-  o> 

ON  0    O    ■*•  N  NO 


no   t^  t^,  g  00  iO  • 


0>  On  On  On  On  ( 


in  which  the  case  is  under  the  supervision  of  a  private  phy- 
sician, that  reasonable  and  necessary  precautions  for  the 
protection  of  others  will  be  taken.  If,  however,  the  con- 
sumptive has  the  diseases  in  an  infectious  stage  and  is  with- 
out a  home,  or  is  living  in  a  lodging  house,  or  in  a  poorly 
furnished  room,  or  in  a  family  in  a  tenement  house,  or  is 
receiving  charitable  medical  advice  through  some  public  in- 
stitution, then  all  objection  to  the  interference  or  the  super- 
vision of  the  authorities  is  removed,  and  in  the  interests  of 
the  public  such  interference  and  supervision  become  neces- 
sary. Such  is  the  attitude  which  has  been  adopted  in  New 
York  City.  It  is  assumed  and  stated  positively  that  in  all 
instances  where  the  consumptive  is  under  the  care  of  a  pri- 
vate physician  and  the  latter  will  undertake  to  give  such 
instructions  as  are  necessary  to  prevent  the  transmission  of 
the  disease  to  others,  no  further  cognizance  of  the  case  will 
be  taken  by  the  health  authorities  after  the  registration. 

The  fact  should  be  strongly  emphasized  again,  that  the 
mere  fact  of  notification  and  registration  has  in  itself  a 
very  powerful  educational  influence.  During  the  year  1902 
more  than  16,000  cases  were  reported  to  the  Department 
of  Health  in  New  York  City,  of  which  4,200  were  dupli- 
cates, and  in  1906  more  than  30,000  cases  were  reported, 
of  which  over  10,000  were  duplicates. 

2.  To  facilitate  the  early  and  definite  diagnosis  of  all 
cases  of  pulmonary  tuberculosis,  the  sanitary  authorities 
should  afford  facilities  for  the  free  bacteriological  examina- 
tion of  the  sputum  in  all  instances  of  suspected  disease.  In 
a  large  proportion  of  the  cases  of  early  disease  the  physical 
signs  and  the  symptoms  are  not  sufficiently  definite  to  permit 
a  positive  diagnosis  by  the  general  practitioner.  An  expert 
may  easily  arrive  at  a  positive  conclusion,  but  the  general 
practitioner  remains  in  serious  doubt.  In  the  absence  of  a 
positive  result  from  an  examination  of  the  sputum,  the  at- 
tending physician  awaits  the  appearance  01  more  definite 
signs,  and  thus  too  often  loses  most  valuable  time,  for  these 
more  definite  signs  mean  further  extension  of  the  disease  in 
the  lungs.  In  some  institutions  and  with  many  physicians, 
the  positive  position  is  assumed  that  no  case  is  to  be  re- 
garded as  tuberculosis  of  the  lungs  unless  tubercle  bacilli  are 


found  in  the  sputum.  I  need  hardly  point  out  how  erron- 
eous and  dangerous  is  this  opinion. 

It  is  of  course  of  vital  importance  that  the  diagnosis  in 
every  case  should  be  made  at  the  earliest  possible  moment. 
A  large  proportion  of  the  medical  profession,  in  the  large 
cities  particularly,  have  not  the  facilities,  nor  are  they  compe- 
tent to  make  such  bacteriological  examinations.  The  De- 
partment of  Health  of  New  York  City  provided  facilities  for 
such  examinations  in  1894,  early  in  the  history  of  its  at- 
tempt to  exercise  control  over  the  disease,  and  this  proced- 
ure has  proved  of  very  great  value  to  the  medical  profes- 
sion, to  the  sick,  and  to  the  authorities.  Following  the  ex- 
ample of  New  York  City,  other  sanitary  authorities  have 
adopted  similar  measures,  and  I  think  it  is  the  general  opin- 
ion now  that  such  free  bacteriological  examinations  should 
be  made  by  the  authorities,  and  that  every  convenience  and 
facility  for  them  should  be  afforded.  It  is  a  curious  fact 
in  this  connection  that  large  numbers  of  physicians  in  pri- 
vate practice  who  are  unwilling  or  reluctant  to  directly  re- 
port cases  of  tuberculosis,  without  hesitation  send  specimens 
of  sputum  for  examination,  with  all  the  facts  in  relation  to 
the  patient  which  are  necessary  for  registration.  It  is  only 
on  this  condition  that  the  examinations  are  made.  During 
the  year  1906  more  than  21,000  specimens  of  sputum  were 
examined  in  the  laboratories  of  the  Department  of  Health. 
These  specimens  came  almost  entirely  from  physicians  in 
private  practice.  There  are  about  300  depots  in  New  York 
City  where  the  outfits,  blanks,  etc.,  for  the  collection  of  speci- 
mens of  sputum  may  be  obtained  and  where  the  specimens 
may  be  left  for  the  Department  collectors. 

3.  Educational  Measures. — It  is  difficult  to  overestimate 
the  importance  of  the  duties  of  the  sanitary  authorities  in 
the  education  of  the  medical  profession  and  of  the  people 
on  the  subject  of  tuberculosis.  Circulars  designed  to  reach 
different  classes  of  the  community  and  covering  different 
phases  of  the  subject  should  be  widely  distributed,  and  the 
public  press  should  be  utilized  to  the  very  largest  extent  in 
the  diffusion  of  information.  The  circulars  as  issued  should 
be  given  to  the  press  for  general  publication.  A  very  im- 
portant function  is  performed  in  this  connection  by  the  vari- 


ous  lay  societies,  associations,  leagues,  etc.,  organized  for 
the  prevention  of  this  disease.  By  the  means  of  circulars 
widely  distributed  through  every  possible  channel,  and  gen- 
eral agitation  in  the  lay  press  and  numerous  and  repeated 
lectures  before  all  classes  of  the  community,  a  very  broad 
dissemination  of  knowledge  as  to  the  nature  of  tuberculosis 
and  the  means  to  be  adopted  for  its  prevention  may  be  at- 
tained.    I  need  not  further  refer  to  this  phase  of  the  subject. 

4.  The  Visitation  of  Consumptives  in  Their  Homes. — An 
important  part  of  the  work  of  the  authorities  consists  in  the 
immediate  visitation  by  a  physician  or  trained  nurse  of  every 
case  of  tuberculosis  not  under  the  care  of  a  private  physi- 
cian or  in  a  public  institution  as  soon  as  it  is  reported.  At 
these  visits  verbal  instructions  should  be  given,  and  printed 
circulars  left  for  the  information  of  the  patient  and  the  fam- 
ily. At  the  same  time  data  should  be  gathered  as  to  the  his- 
tory of  the  sick  person  and  of  the  family,  its  social  condition 
and  financial  income,  the  number  of  persons  in  the  family 
and  their  wages ;  the  number  of  cases  of  tuberculosis  which 
have  occurred,  the  probable  source  of  infection  in  the  in- 
dividual ;  the  sanitary  condition  of  the  premises,  the  amount 
of  air  space  for  each  person,  the  character  of  the  light  and 
ventilation,  the  precautions  being  observed  and  the  possible 
need  of  any  further  interference  on  the  part  of  the  authori- 
ties. In  the  course  of  these  visits  it  becomes  evident  in  many 
instances  that  a  patient  should  be  removed  to  a  hospital  or 
sent  to  a  sanatorium  outside  of  the  city.  In  such  instances, 
if  possible,  the  patient  should  be  induced  by  persuasion  to 
avail  himself  or  herself  of  such  institutional  care  as  seems 
desirable  or  available.  If  the  patient  persistently  refuses  in- 
stitutional care,  forcible  removal  must  be  resorted  to  in 
those  instances  in  which  the  unsanitary  conditions  existing 
render  it  necessary. 

5.  The  disinfection  or  renovation  of  rooms  or  apartments 
which  have  been  vacated  by  consumptives  either  by  death 
or  removal.  Trained  medical  inspectors  should  be  sent  when- 
ever it  comes  to  the  knowledge  of  the  authorities,  that  prem- 
ises have  been  vacated  by  death  or  removal,  and  proper 
measures  adopted  to  enforce  disinfection  of  the  premises 
by  means  of  formaldehyde  gas,  or  thorough  renovation.     In 


13 

those  instances  in  which  the  premises  are  dirty  and  filthy, 
and  the  walls  and  ceilings  are  in  bad  condition,  renovation, 
to  be  performed  by  the  owners,  should  be  required.  If  nec- 
essary for  this  purpose,  the  apartments  may  be  vacated,  or  if 
already  vacant,  the  occupation  by  others  must  be  prohibited 
until  such  renovation  has  been  completed.  Carpets,  rugs, 
clothing,  pillows  and  mattresses,  and  any  bedding  or  other 
textile  fabrics,  which  cannot  be  properly  disinfected  by 
formaldehyde,  should  be  removed  by  the  authorities,  and 
subjected  to  steam  disinfection.  Disinfection  should  be  car- 
ried out  by  the  health  authorities  without  cost  to  the  occu- 
pants or  owners,  but  the  cost  of  renovation,  when  required, 
should  be  borne  by  the  owner,  of  the  premises. 

A  serious  difficulty  exists  in  this  connectoin  because  of 
the  frequent  changes  of  residence  of  some  families  contain- 
ing consumptives;  and  as  the  families  become  constantly 
poorer  on  account  of  the  financial  loss  and  expense  entailed 
by  the  illness,  they  move  continually  to  a  poorer  and  poorer 
class  of  tenements.  It  is  often  impossible  to  trace  them,  or 
to  obtain  information  of  their  change  of  residence,  so  that 
proper  disinfection  of  the  apartments  may  be  ensured.  The 
owners  of  the  property  may  of  course  be  required  to  fur- 
nish information  of  the  removal,  but  there  is  danger  lest  this 
course  may  eventually  entail  some  hardship  on  the  poor 
consumptive  in  rendering  it  more  difficult  for  him  to  find 
lodgings.  This  is  the  most  troublesome  problem  to  solve 
which  we  have  found  in  New  York.  I  do  not  feel  sure  that 
eventually  notification  by  the  owner  of  the  removal  of  a 
consumptive  will  not  be  necessary,  as  the  only  solution  of 
this  difficulty. 

6.  Provision  should  be  made  for  making  repeated  visits 
to  cases  in  tenement  houses,  when  for  any  reason  it  has 
been  undesirable  or  impossible  to  remove  the  patient  to  an 
institution.  These  revisits  may  usually  be  best  made  by 
trained  nurses.  In  this  way  information  may  be  gathered  as 
to  changes  of  residence,  as  to  the  efficiency  of  the  precau- 
tions adopted  by  the  consumptive,  as  to  the  changes  in  his 
physical  condition  or  the  financial  resources  of  the  family, 
and  as  to  the  necessity  of  any  alteration  required  in  the 
sanitary  treatment  of  the  case. 


M 

7.  Suitable  food,  especially  milk  and  eggs,  should  be  pro- 
vided by  the  sanitary  authorities  or  by  other  authorities  hav- 
ing supervision  of  such  affairs  in  those  instances,  in  which 
the  families  are  in  such  destitute  circumstances,  that  proper 
or  sufficient  food  cannot  be  obtained  by  them,  and  when  the 
patient  for  any  reason  cannot  be  removed  to  an  institution. 
Some  very  difficult  economic  problems  are  presented  in 
some  of  these  cases.  For  example:  A  family  consists  of  a 
mother  with  moderately  advanced  consumption  and  five 
small  children ;  the  father  is  dead ;  the  income  of  the  family 
from  all  sources  is  insufficient  to  maintain  it  properly  and 
furnish  the  mother  with  suitable  food.  But  the  apartments 
are  well  ventilated  and  sufficiently  commodious,  they  are 
clean  and  neat,  and  the  mother  makes  every  effort  to  obey 
every  instruction  and  heed  every  suggestion.  She  insists 
on  remaining  with  her  children,  and  her  presence  is  neces- 
sary to  keep  the  family  together.  Undoubtedly  the  mother 
would  be  better  off  in  an  institution,  and  thus,  too,  the  chil- 
dren would  be  removed  to  an  institution  for  children,  and 
would  be  better  protected  from  the  danger  of  tubercular 
infection.  But  then  the  children  grow  up  as  institutional 
children,  which  is  most  unfortunate,  and,  furthermore,  there 
is  no  sufficient  sanitary  ground  for  the  forcible  removal  of 
the  mother.  Under  such  conditions,  for  the  present  at  least, 
I  believe,  the  authorities  should  provide  or  see  that  there 
is  provided,  such  food  or  other  assistance  as  is  required. 

If,  however,  the  apartments  are  dirty  and  not  well  kept, 
or  are  small,  dark,  and  badly  ventilated,  or  the  instructions 
are  not  followed  and  proper  precautions  are  not  taken,  then 
the  family  should  be  broken  up,  the  mother  should  be  re- 
moved to  an  institution,  if  necessary  by  force,  and  the  chil- 
dren otherwise  provided  for. 

No  uniform  regulations  can  be  laid  down  for  the  disposi- 
tion of  such  cases,  but  each  one  must  be  considered  on  its 
merits,  and  the  ultimate  decision  in  each  instance  determined 
after  a  careful  consideration  of  all  the  facts. 

The  authorities  should,  however,  recognize  their  respon- 
sibilities as  to  the  provision  in  some  instances  of  food,  or 
other  assistance,  and  should  have  means  at  their  disposal  for 
this  purpose.    If  this  assistance  is  dispensed  by  other  author- 


15 

ities  than  the  health  authorities,  it  should  be  under  the  lat- 
ter's  direction  and  supervision. 

8.  The  sanitary  authorities  should  provide,  or  see  that 
there  are  provided,  and  should  supervise,  three  classes  of  in- 
stitutions for  consumptives : 

Free  Dispensaries. — In  these  free  dispensaries  medical 
treatment  for  ambulatory  cases  should  be  provided.  These 
cases  should  be  constantly  under  the  supervision  of  the  dis- 
trict physicians  and  nurses  attached  to  the  dispensary. 
Where  necessary,  not  only  medicines,  but  food,  should  be 
furnished  free  by  the  dispensary  to  the  consumptive  poor. 
The  dispensaries  should  also  act  as  clearing  houses  for  con- 
sumptives, and  should  serve  as  places  to  which  all  institu- 
tional cases  on  their  discharge  from  institutions  and  all 
poor  cases  receiving  the  care  or  assistance  of  charitable  or- 
ganizations should  be  referred  for  medical  care.  From  this 
dispensary  suitable  cases  should  be  referred  to  either  a  sana- 
torium or  a  hospital,  as  seems  necessary. 

Hospitals  for  the  Care  of  Advanced  Cases. — It  is  not 
necessary  that  all  the  hospitals  for  the  care  of  advanced 
cases  should  be  directly  under  the  control  of  the  sanitary 
authorities,  although  they  should  exercise  a  general  supervi- 
sion over  these  institutions.  It  is  necessary,  however,  at 
least  in  a  very  large  city,  that  the  authorities  should  have 
control  of  at  least  one  institution  with  adequate  facilities  for 
the  care  of  certain  varieties  of  advanced  cases  of  the  disease, 
which  it  may  be  necessary  to  forcibly  remove  to  the  institu- 
tion and  retain  there  against  their  will.  These  are  of  sev- 
eral types :  First.  Those  which  are  discharged  from  other 
institutions,  because  they  are  from  the  institutional  stand- 
point exceedingly  undesirable  patients,  or  because  they  have 
violated  the  regulations  of  the  institution.  A  moment's  con- 
sideration will  show  that  the  sanitary  point  of  view  and 
that  of  the  authorities  of  an  institution  widely  differ.  In 
order  to  maintain  the  discipline  of  an  institution  cases  which 
persistently  violate  its  regulations  must  be  dismissed.  From 
the  sanitary  standpoint,  these  are  of  all  cases  those  which  it 
is  specially  important  should  be  provided  with  institutional 
care.  Homeless,  friendless,  dependent,  dissipated  and  vi- 
cious  consumptives  are  those  which  are  likely  to  be  most 


16 

dangerous  to  the  community.  If  not  cared  for  in  an  insti- 
tution, they  are  wandering  from  place  to  place,  living  in 
lodging  houses  or  sleeping  in  hallways  or  wherever  cover 
can  be  found ;  negligent  as  to  the  disposal  of  their  expectora- 
tion, and  disseminating  infection  in  every  place  which  they 
visit.  Such  cases  must  be  provided  for  by  the  sanitary  au- 
thorities at  any  cost,  and  if  necessary  they  must  be  removed 
by  force  to  proper  institutions  and  there  detained. 

Second. — Cases  living  in  lodging  houses,  or  those  which 
are  inmates  of  public  institutions  not  having  facilities  for 
their  care,  who  are  unwilling  to  enter  any  of  the  institutions 
which  are  available,  must  be  provided  for  and  must  be  in 
the  same  way  removed,  by  force  if  necesary,  and  detained. 

Third. — It  not  infrequently  becomes  necessary  in  a  large 
city  to  remove  from  their  homes,  cases  which  are  almost 
necessarily  sources  of  danger  to  the  other  members  of  their 
family;  in  those  instances  in  which  the  sanitary  conditions 
are  very  unfavorable,  when  there  is  great  poverty,  destitu- 
tion, or  overcrowding,  and  when  the  patients  themselves  are 
unwilling  to  enter  an  institution,  the  health  authorities  must 
intervene  and  remove  such  patients  by  force  and  detain 
them. 

Fourth. — There  are  numerous  cases  which  have  already 
been  under  the  care  of  an  institution,  and  which  become 
for  some  reason  dissatisfied  with  their  care  and  are  deter- 
mined to  return  to  their  homes.  In  these  instances  when  the 
family  is  unwilling  or  unable  to  provide  properly  for  them, 
the  patients  should  be  removed  by  the  health  authorities  and 
retained  under  supervision. 

It  will  be  readily  understood  that  the  classes  of  cases, 
which  have  been  referred  to  as  necessarily  coming  under  the 
supervision  of  the  health  authorities  are  generally  very  un- 
desirable and  difficult  to  control.  Yet  the  experience  of  the 
Department  of  Health  of  New  York  has  shown  that  rarely 
is  any  real  difficulty  experienced  in  the  management  of  these 
cases,  if  the  accommodations  which  are  provided  and  the 
food  and  care  given  are  of  a  superior  character.  It  will  be 
readily  understood  that  the  measures  suggested  here  can 
only  be  taken  where  the  sanitary  authorities  have  full  power 
and  control,  and  that  patients  can  be  retained  only  in  insti- 


17 

tutions  over  which  they  have  direct  authority.  So  far  as  I  am 
aware  the  forcible  removal  of  tuberculous  patients  has  not 
been  attempted  by  any  sanitary  authorities  excepting  those 
in  New  York  City. 

Sanatoria. — The  sanitary  authorities  should  provide  or 
have  available  proper  sanatoria  in  favorably  situated  coun- 
try districts  for  the  care  of  early  and  incipient  cases.  No 
further  comments  seem  necessary  on  this  phase  of  the  sub- 
ject. It  is  evident  that  as  the  authorities  have  to  deal  with 
both  the  prevention  and  care  of  tuberculosis,  such  institu- 
tions are  imperatively  demanded.  As  has  often  been  pointed 
out,  every  early  case  removed  to  a  sanatorium  not  only  re- 
moves the  individual  who  may  be  for  a  long  period  a  source 
of  danger  to  others,  but  also  affords  the  best  chance  for  re- 
covery. Such  patients  when  cured  and  discharged  from  the 
sanatorium  are  educational  factors  of  no  small  moment  in 
the  community. 

9.  The  sanitary  authorities  should  issue  regulations  ap- 
plicable to  public  institutions  as  to  the  care  of  consumptives. 
The  admission  and  treatment  of  such  patients  in  the  general 
wards  of  general  hospitals  should  be  prohibited,  and  all  pub- 
lic institutions  caring  for  such  patients  should  be  required 
to  provide  separate  rooms  or  wards.  These  regulations  should 
apply  not  only  to  general  hospitals,  but  also  to  the  hospitals 
for  the  insane,  to  penal  institutions,  homes,  asylums,  etc. 
Suitable  regulations  should  be  formulated  in  regard  to  cases 
occurring  among  the  teachers  or  pupils  in  the  public  schools 
and  as  to  employees  in  factories,  workshops  and  mercantile 
establishments,  and  as  to  occupations  of  a  nature  which 
are  likely  to  disseminate  the  disease. 

10.  The  sanitary  authorities  should  enact  and  enforce 
regulations  prohibiting  spitting  in  all  kinds  of  public  con- 
veyances, such  as  street  cars,  steam  railroad  cars,  ferry- 
boats, etc.,  and  on  the  floors  of  public  buildings  and  places  of 
public  assembly,  such  as  ferry-houses,  depots,  etc.,  and  in 
the  halls  of  tenement  houses,  theaters,  in  factories,  etc.  Spit- 
ting on  the  sidewalks  should  also  be  prohibited. 

The  fundamental  importance  of  the  careless  disposal  of 
sputum  in  the  causation  boith  of  pulmonary  tuberculosis 
and  the  acute  respiratory  diseases  has  not  been  fully  recog- 


iS 

nized,  I  believe.  It  seems  to  me  that  here  is  the  keynote  to 
the  whole  question  of  the  prevention  of  the  diseases  of  the 
respiratory  organs.  In  various  forms  of  pneumonia  as  well 
as  in  tuberculosis,  the  causative  microorganisms  are  found 
in  the  secretions  of  the  respiratory  tract ;  and  when  these  se- 
cretions are  not  properly  destroyed  at  the  time  of  their  dis- 
charge from  the  body,  they  become  more  or  less  widely 
scattered,  dried,  pulverized  and  suspended  in  the  air  as  dust. 
Practically  all  of  the  organisms  causing  these  diseases  belong 
to  the  class  which  do  not  find  favorable  conditions  for  their 
multiplication  outside  of  the  living  body,  and  therefore  when 
they  are  effective  in  the  causation  of  disease  it  is  because  they 
have  been  derived  definitely  from  some  other  single  case  of 
disease.  It  is  of  vital  importance  in  the  propaganda  for  the 
prevention  of  tuberculosis  and  also  of  pneumonia,  that  we 
should  educate  all  classes  of  the  people  to  a  recognition  of 
and  a  belief  in  the  fundamental  importance  of  the  proper 
disposal  of  the  expectoration  and  should  gradually  inculcate 
the  idea  that  the  habit  of  spitting  carelessly  anywhere  is  not 
only  filthy  and  indecent,  but  as  in  many  instances  to  be  re- 
garded as  almost  criminal.  When  we  have  educated  the  mass 
of  people  up  to  this  view,  so  that  this  habit  of  spitting  will 
not  be  tolerated,  the  chief  factor  in  the  solution  of  the  prob- 
lem of  the  prevention  of  tuberculosis  will,  in  my  opinion, 
have  been  found. 

A  number  of  measures  of  minor  importance  in  the  sur- 
veillance of  the  tuberculous  diseases  have  been  in  operation 
in  New  York  City.  Among  these  may  be  mentioned  the 
semi-annual  census  of  the  cases  of  pulmonary  tuberculosis 
under  treatment  in  public  institutions  in  the  city.  It  has  also 
been  the  custom  during  the  last  two  or  three  years  to  com- 
municate with  the  attending  physician  in  cases  of  tubercu- 
losis, which  have  been  reported  through  the  sputum  exami- 
nation or  directly,  and  to  enquire  whether  the  patient  is  still 
under  treatment,  and  if  so,  whether  improvement  has  taken 
place  or  not,  and  whether  the  physician  has  any  objection 
to  a  visit  being  made  to  the  patient  if  he  or  she  is  not  at 
that  time  under  his  observation.  Tf  the  physician  replies  that 
the  patient  has  passed  from  his  observation,  and  he  Has  no 
objection  to  an  investigation  by  the  department,  an  effort  is 


19 


< 


N?2 


1894-1898 


BATAVIA  ST. 

0* 

JJ 

o 
n 

Wl 

cr> 

m 
< 
m 

\  n 

NV\ 

r- 

H 

mm 

Ik 

ST. 


1899-1903 

Infected  Areas  in  Lower  New  York. 


made  to  locate  the  patient  and  determine  what  the  condi- 
tion is. 

Sanitary  cuspidors  are  supplied  by  the  department 
through  trained  nurses  for  the  use  of  patients  who  are  very 
poor  in  the  tenement  house  districts,  and  large  numbers  of 
these  cuspidors  have  also  been  supplied  to  various  charitable 
societies,  which  have  supervision  of,  or  are  extending  help  to 
cases  of  consumption  in  their  homes. 

Large  numbers  of  circulars  of  information  have  also  been 
supplied  to  these  societies  for  distribution,  and  similar  circu- 
lars in  various  languages  have  been  furnished  to  various 
labor  unions  for  distribution  among  their  members. 

The  inspectors  of  the  Tenement  House  Department,  in 
the  course  of  their  house-to-house  inspection,  report  to  the 
Department  of  Health  any  cases  of  apparent  tuberculosis 
which  they  may  find,  and  these  are  investigated  by  the  De- 
partment of  Health. 

In  the  very  beginning  of  the  work  in  New  York  sec- 
tional maps  of  the  Borough  of  Manhattan  were  prepared 
showing  every  house  lot  in  the  borough  on  a  sufficiently 
large  scale  so  that  all  cases  of  tuberculosis  which  came  un- 
der the  observation  of  the  department  and  all  deaths  from 
this  disease  could  be  plotted,  to  show  the  topographical  dis- 
tribution of  the  disease.  I  have  had  some  of  these  repro- 
duced to  show  the  extraordinary  prevalence  of  the  disease  in 
some  of  the  crowded  tenement  house  districts. 

Attempts  are  now  being  made  to  secure  the  condemnation 
by  the  city  of  several  areas  in  the  tenement  house  districts 
in  which  tuberculosis  has  been  particularly  prevalent. 

One  minor  measure  which  has  been  found  of  much 
service  in  New  York  has  been  the  house-to-house  inspec- 
tion in  tenement  house  districts  by  women  physicians  in  the 
search  for  unreported  cases  of  tuberculosis.  Quite  a  large 
number  of  such  cases  have  been  found  in  this  way,  especially 
among  the  foreign  population.  It  is  also  of  the  greatest  im- 
portance in  this  connection  that  the  trained  nurses  and 
medical  inspectors  should  know  the  language  of  the  people 
whom  they  are  visiting.  Great  care  has  been  taken,  as  far 
as  it  was  possible  under  the  civil  service  regulations,  to  ob- 
tain trained  nurses  and  physicians  who  speak  foreign  Ian- 


23 

guages.  We  have  now  engaged  in  this  work  nurses  who 
speak  French,  German,  Yiddish,  Russian,  Italian  and  Polish. 

These  measures  as  detailed  seem  to  me  to  include  the 
more  important  provisions  of  a  scheme  for  the  efficient  ad- 
ministrative control  of  tuberculosis.  Several  questions  arise 
in  this  connection :  ( i )  Is  such  a  scheme  feasible  and  prac- 
ticable? (2)  Are  there  serious  objections  to  the  enforcement 
of  the  measures  proposed?  (3)  What  results  may  be  rea- 
sonably expected  from  the  enforcement  of  such  measures  ? 

In  answer  to  the  first  question — Is  such  a  scheme  of 
sanitary  surveillance  of  tuberculosis  feasible  and  practicable  ? 
— I  would  say  decidedly,  it  is.  In  its  main  and  most  impor- 
tant features  such  a  plan  has  been  in  force  in  New  York  City 
for  a  number  of  years.  The  feasibility  and  the  practicability 
have  been  conclusively  demonstrated  by  an  experience  in  the 
second  largest  city  in  the  world.  In  only  a  few  of  the  less 
important  details  is  the  general  plan  as  now  followed  in 
New  York  wanting.  Referring  to  these  measures  specifi- 
cally, it  may  be  said  as  to  registration  that  20,000  new  cases 
were  registered  in  the  year  1906  in  New  York  City ;  and  over 
21,000  specimens  of  sputum  were  examined.  Large  numbers 
of  circulars  of  various  kinds  designed  to  reach  different 
classes  of  the  community  are  being  and  have  been  issued 
each  year.  During  the  one  year  over  100,000  "Circulars  of 
Information  for  Consumptives  and  Those  Living  with 
Them"  were  issued  by  the  Department  of  Health.  These 
were  printed  in  many  different  languages,  for  example: 
English,  German,  Italian,  Yiddish,  Chinese,  Russian,  Ruthe- 
nian,  Polish,  etc. 

All  cases  of  tuberculosis  reported  to  the  department  not 
under  the  direct  care  of  a  private  physician  are  regularly 
visited  by  medical  inspectors  and  trained  nurses,,  and  the 
main  facts  in  regard  to  the  individual,  family,  sanitary  con- 
ditions of  the  premises,  etc.,  are  gathered ;  instructions  are 
given  and  circulars  of  information  left.  All  rooms  or  apart- 
ments which  have  been  vacated  by  consumptives  either  by 
death  or  removal,  so  far  as  the  department  can  obtain  such 
information,  are  either  immediately  disinfected  or  renova- 
tion is  ordered  and  their  occupation  by  others  prohibited  un- 
til the  orders  are  complied  with.  Carpets,  rugs,  pillows,  mat- 


24 

tresses,  etc.,  are  removed  by  the  department,  disinfected  by 
steam,  and  returned.  Provision  is  made  for  continuous  su- 
pervision of  such  cases  as  remain  in  tenement  houses  and 
require  such  supervision,  through  specially  trained  nurses 
and  medical  inspectors. 

Special  dispensaries  for  the  treatment  of  consumptives 
have  been  provided  in  Manhattan,  Brooklyn  and  The  Bronx, 
where  treatment,  medicines  and  necessary  food  (milk  and 
eggs)  are  furnished  free  of  charge.  Some  years  ago  a  series 
of  pavilions  was  opened  at  Riverside  Hospital  on  North 
Brother  Island  by  the  Department  of  Health  for  the  care  of 
those  whom  it  is  necessary  to  remove  by  force  and  detain, 
such  as  the  undesirable  and  insubordinate  cases  discharged 
from  other  institutions,  and  also  homeless,  friendless  and 
vicious  cases. 

A  sanatorium  for  the  care  of  incipient  cases  among  the 
poor  has  been  opened  at  Otisville,  New  York,  where  eventu- 
ally 200  or  more  patients  will  be  accommodated.  Only  early 
favorable  cases  are  admitted. 

Regulations  have  been  enacted  relating  to  careless  expec- 
toration, and  to  a  considerable  extent  have  been  enforced 
in  public  conveyances.  The  regulations  prohibiting  spitting 
on  sidewalks,  in  the  public  halls  of  public  buildings,  tene- 
ment houses,  etc.,  have  not  as  yet  been  enforced,  although  it 
is  proposed  to  soon  adopt  more  active  steps  in  this  direction. 

The  Department  of  Health  of  New  York  City,  with  the 
exception  of  the  special  diet  above  referred  to,  has  not  as 
yet  undertaken  to  provide  food  or  assistance  to  the  consump- 
tive poor  living  at  home,  where  for  any  reason  they  cannot 
or  should  not  be  removed,  neither  has  it  undertaken  to  pro- 
vide full  regulations  for  the  supervision  of  such  cases  in  pub- 
lic institutions,  in  the  public  schools  and  as  regards  em- 
ployees in  factories,  and  occupations  in  which  consumptives 
are  likely  to  be  a  source  of  danger. 

Excepting  in  these  respects,  the  scheme  as  presented 
has  been  practically  in  force  for  a  number  of  years  in  New 
York  City,  the  extent  and  the  strictness  of  the  supervision 
having  each  year  during  the  last  ten  years  been  materially 
increased.  What,  therefore,  is  practicable  and  feasible  in 
New  York  should  be  practicable  and  feasible  in  cities  of 


25 


■U1BX3  tnmndg 


S3jE0i[driQ 


S3JF0I(dnQ 

*oui  psjjods^j 


(s*\0  no  m  «  r*.  «  -f->o  ~  •**■ 

^-  U"l  O    «    M    m    O  ""•'©    Q    <^00 

)t-co  •>»  o*  >-  iof*o  f-*o  •*;  ^2 

^►TeTerroro-r'^t^.O''-'    "-* 


o  w  o   moo  CO  CO  vO    M 

ro  i>.  co  0  n»no  O 

CM    ■*  -I"  0,   N«0    M_  «_ 

cT  N*  cT  CO  ro  ^-vO   o»oo 


vO    M-  **■  lOCO    *}-  O  «n  ro  t^.  h    w    « 

\0  «  m  ro  ooo  m  roco  co  m^j-a 
mcd    mNN  -^vo   •-»    ro  r»  -1-  »■«    C 


<  vo    «    mvoiO    O 


m    l>.CO    NO>-<OvOtv.-*-ro  ("-.CO    O 

o  h  oco  Kco  lo  -a-  ro  -j-  >-<  a^m  r**vo  m  uivo  m  *<*•  w  mnniri 
444f^nfomnnnfOM  «'  «  w  cJ  «  «  c*  c-i  o!  «  ci  ci  w"  w 


uo  "ojsqnx 

JO   "5U33  13£ 


irjvo    t^-00  VO    OM( 
CO    Os  **■  Cl  VO   O  ■*■  ' 


tN  CO    O  f-  ui  O  t-»  -J-  Cn  O'O    O  t^.  t-v  O    O*  -t-  fl 


O  OO  CO  CO    -t-  «  CO 


Q>  f^vO  CO    o 


siso[noj3qnx 
J3qjQ  sqWQ 


O   mO   ■**-  r-  -**-<-  vo 


r^.  c^co  Ok  n  oo 


iTI-NO    m 


C*-C0  CO    OOO    O    O    C    OOnOiOi  OCO  CO  CO    IN-VO    !>• 


sxsiqiqj 
sqiusQ 


vN   t>.  o  uivo   r^.  o   o  o  «   O 
m  ^-OfOO  t-vo  vo  r*-  ovo 


■  ro  t^zo  co  ro  < 


-t-  o  ao  f?«  m  t>-  -o  t-* 
O  m  rt  r»0O  CO  ^-O  r-* 
ro  ^  ir.vo"  tC  *TvO  CO 


ip  hoc 


«    *TTiAC>' 


invo  sorsNCO  w  vo 


-oiaqnx  Tl  V 


l  vo    O-vO    t*-vo 


OOO    O    u-l  ro  0    »-•  O    « 


sq^Bsci 

sisojnoisqnx 


cow  to  OMn  o  N  fi  m  o\O^M  mo  rovo  m  h  aOMJ'  -d-vo  moo  vo 
o  m  -<f  ro  ^-rt-o  NtO  0  vo  vo  cjoo  o  o  O  C  i>-  -r  -*-co  i>»  ^-  av 
w  O  0>  O  ar^O  0  O  Tt-M  O  w  t^  O  ^  NO^  m  C_  i>-  0_  «_  (OO^ 
vo'vo'  invO^  in\o\*^0**0  *o"*0  tO  ^O   invO*"  iO  >D  i^vO  VO*  VO    lOO  VOVO  "O 


31^-^  qaBSQ 

113J3U3Q 


«  o 


iOO«    Of    r***-1   inQvoco   «■*■  rovo 


"^■'S-M    T*-f)    m    rOW)OvCOO>  ONVO    i 

«  w  ft  p*.co  w  m  ts  tv  o  ir>Mco  i 
vq_C;0  Ovo  roq;wvo  w_vo  ro  ^t-  » 
co*"  tC  -^  in  to  rCco"  o"  ci  O*  fo  ■*  -^  ■ 


.co  m   o.r^^o^.  c^co 
.  m,  m   n  o  0   to-OO 

«^-  O  C»    fO  C^  C^VO^  N    M^ 

6"  Ov  ro  ro  »-*"•-<  co  u".  o 


iMflHCO    T  '■ 


S"S  3^  ^  K.  5  S  • 

tCso'co  CO    C*-CC  CO  CO  CO 


c>  o  a«  ■*■  cj  vo  o  o  i 


m  m  0  o^rs  -i-co 
\o  t-^  r**,co  co  co  "^  "^ 
ci  uivc  r^co  c^  t^vo_  m 
c>  o^  6*^  cico  c  ov  o  c 


C*    t  in  O"1  "1  O  O^  f*l  ' 


CItShh«30h( 

w   roco  t-v  ►*  O*  c>  t^  ( 

VO  vO    t»  C^O  >C    NNN 


«    0\  *  **■  O    CO 


'.CO 


'J-CO    0 

_  ^  ^  ^1  M^  ^2°°^.  ^^L  I  °^ 
o" co  vo'vo  eC  c?  eTvo"  «*  Soaco 

cj   ro  ro  ro  -t-  t?-  in  mvo  vo  r>N( 


o  ro  ■•*-  uivo  t^-co  ov  0 


Ovrot^O  ^00  0  ^  «  ei 
u  ro  in  c*  ro  m  o  r'.oo  roco  r^" 
«  m  lomroNcioovoco  ro^t- 

rovo*  o"vo*^  -?  "^00    W    »-^CO    0 

t^O  -r^-1  mMCO  tw  ov_ 
CO  oaoO   0    m    -<N    roro* 


oo  «  «   o  m  ro  ro  ( 
^  t--  o  cTorj  »r  O  t^cb_ 

i>  in  "*•  mvo  co  0  ( 

a  m  •*■  mvo^  t;  r>  C  "_ 
rororoforororo^^ 


-j-  mo  o-oo  <rv  | 


ujCOCOOOCOCOCOCOCO     00-*    ?    *    ^-     -     Cj     C     OC     0     C 
COCOCOCOCOCOCOCOCOCOCOCOCOCOrJOCOCOOOOO    ^OiOOiOO* 


^  c> 


Bo  OQ    5  5    -     c~    5  iQ    5 


26 

smaller  size,  and  it  should  be  possible  to  enforce  more  read- 
ily and  more  satisfactorily  similar  regulations  in  them. 

As  to  the  second  question — Are  there  serious  objections 
to  the  enforcement  of  such  a  scheme,  or  are  the  objections 
valid  which  have  been  urged  by  some  authorities? — the  re- 
ply to  this  is  decidedly  in  the  negative.  Very  great  opposi- 
tion met  the  proposition  of  the  Department  of  Health  of 
New  York  to  undertake  this  work  in  the  beginning  and 
many  difficulties  were  encountered  in  the  early  years  owing 
to  this  opposition.  But  experience  has  shown  that  the  ob- 
stacles are  largely  imaginary  ;  that  the  harmful  results 
which  were  predicted  as  certain  to  follow  have  failed  to 
materialize.  Practically  no  serious  difficulties  are  en- 
countered in  carrying  on  the  work.  I  would  say  that  the 
difficulties  with  reference  to  the  work  of  the  department  in 
New  York  in  relation  to  tuberculosis  are  really  less  serious 
than  those  encountered  in  connection  with  the  contagious  dis- 
eases. There  has  been  hearty  approval  by  the  majority  of 
the  medical  profession,  and  acquiescence  by  the  remain- 
der. 

In  answer  to  the  third  question — What  may  be  reason- 
ably expected  from  the  enforcement  of  such  measures  ? — we 
find  again  an  answer  in  the  experience  of  New  York.  There 
has  been  a  rapid  fall  in  the  tuberculosis  death  rate  in 
New  York  City,  and  this  notwithstanding  the  fact  that  the 
conditions  in  many  respects  are  most  unfavorable,  because 
of  the  very  dense  population  in  the  great  tenement  house 
districts  of  the  city  and  the  large  element  of  foreign-born 
population.  It  should  be  remembered  that  in  no  city  of  the 
world  is  there  such  a  density  of  population  as  exists  in  many 
of  the  wards  of  the  Borough  of  Manhattan.  In  numerous 
districts  on  the  East  Side  the  population  varies  from  600  to 
800  or  more  persons  to  the  acre,  whereas  the  most  densely 
populated  districts  of  Paris,  London,  Vienna  and  Prague 
have  only  400,  or  less  persons  to  the  acre.  When  this  fact 
is  kept  in  mind  the  difficulty  in  reaching  the  large  foreign- 
born  element  of  the  population,  which  speak  their  native 
tongue  and  retain  their  native  customs,  will  be  appreciated. 
During  the  last  twenty  years  there  has  been  a  decrease 
of  more  than  55  (.67  per  1000  to  .26)  per  cent,  in  the  death 


27 


DEATHS  FROM  PULMONARY  TUBERCULOSIS  AND  TUBERCULAR  MENINGITIS, 
0-15  YEARS,  OLD  CITY  OF  NEW  YORK,  1883-1905. 


c 

u 

V    D 

u 

-a 

«■- 

8  a 
0  V 

c 

u  C 

"   >> 

.<c 

~ 

-  u 

5  m 

hi 

.c 

S*S 

P. .. 

o-5 

5-10 

10-15 

T3 
C 
3 

0 

H 

0 

.0 

_•  c 

u  °  C 

■0  Q.2 
>"   <u  0 

V   = 
«.2 

«  =  2 

1883 

Tubercu- 
lar men- 

ingitis* 

48s 

46 

10 

S4i 

Pulmon- 

ary tu- 

berculo- 

sis 

172 

3° 

59 

261 

802 

0.61 

1884 

T.  M.* 

633 

37 

13 

683 

P.  T. 

207 

36 

55 

298 

981 

0.72 

1885 

T.  M.* 

594 

40 

5 

639 

P.  T. 

200 

35 

6S 

399 

938 

0.67 

0.67 

1886 

T.  M.* 

648 

58 

15 

721 

P.  T. 

216 

38 

48 

302 

1023 

0.71 

1887 

T.  M.* 

57° 

38 

13 

621 

P.  T. 

206 

47 

48 

301 

922 

0.62 

1888 

T.  M. 

440 

53+ 

493 

P.  T. 

IS4 

loot 

254 

747 

0.49 

1889 

T.  M. 

498 

45+ 

543 

P.  T. 

138 

not 

238 

781 

0.50 

1890 

T.  M. 
P.  T. 

500 
151 

44 
39 

12 
53 

556 
543 

799 

0.50 

0.49 

1891 

T.  M. 

524 

48 

11 

583 

P.  T. 

118 

29 

62 

210 

792 

0.48 

1892 

T.  M. 

S4i 

50 

14 

605 

P.  T. 

158 

39 

56 

253 

858 

0.50 

1893 

T.  M. 

542 

54 

11 

607 

P.  T. 

iS7 

34 

68 

259 

866 

0.49 

1894 

T.  M. 

522 

63 

13 

598 

P.  T. 

128 

32 

50 

210 

808 

0.45 

189s 

T.  M. 

526 

43 

16 

585 

P.  T. 

165 

24 

5° 

239 

824 

0.44 

0.42 

1896 

T.  M. 

454 

45 

12 

5" 

P.  T. 

120 

32 

48 

200 

711 

0.37 

1897 

T.  M. 

462 

47 

8 

5i7 

P.  T. 

128 

25 

44 

197 

714 

°-37 

1898 

T.  M. 

481 

49 

10 

54° 

P.  T. 

100 

3i 

45 

176 

716 

0.36 

1899 

T.  M. 

475 

45 

12 

532 

P.  T. 

143 

28 

55 

226 

75S 

0.38 

T.  M. 

447 

57 

18 

522 

1900 

P.  T. 

116 

35 

42 

J93 

7r5 

°-35 

0.34 

T.  M. 

392 

49 

16 

457 

1901 

P.  T. 

117 

28 

55 

200 

657 

0.31 

T.  M. 

400 

59 

14 

473 

1002 

P.  T. 

88 

26 

47 

161 

634 

0.30 

T.  M. 

426 

58 

15 

499 

1903 

P.  T. 

79 

3i 

59 

169 

668 

0.31 

T.  M. 

353 

55 

12 

420 

1904 

P.  T. 

122 

38 

76 

236 

656 

0.2S 

T.  M. 

319 

52 

8 

379 

1905 

P.  T. 

138 

40 

68 

246 

625 

0.26 

1906 

*  Includes  hydrocephalus. 


+  5-J5  years. 


28 

rate  in  children  under  fifteen  years  from  pulmonary  tuber- 
culosis and  tuberculous  meningitis,  these  being  the  two 
forms  of  tuberculous  disease  in  which  an  approximately  ac- 
curate diagnosis  is  likely  to  be  made  in  children.  It  is  pre- 
cisely in  this,  the  youngest  element  of  the  population,  that 
one  would  first  look  for  definite  results  from  the  enforce- 
ment of  measures  for  the  restriction  of  this  disease.  There 
has  also  been  a  decrease  in  the  total  tuberculous  death  rate 
between  1886  and  1906 — a  period  of  twenty  years — of  40 
per  cent. 

A  considerable  fall  in  the  death  rate  from  tuberculosis 
has  been  noted  in  various  countries  and  cities,  and  it  has 
been  maintained  and  apparently  shown  that  the  decrease 
was  only  in  small  part  a  real  decrease  and  was  accompanied 
by  an  almost  equal  increase  in  the  death  rate  from  the  acute 
pulmonary  diseases,  notably  pneumonia.  The  claim  has 
been  made  that  there  has  been  simply  a  substitution  in  the 
death  returns  of  pneumonia  for  tuberculosis.  Very  great 
care  has  been  taken  in  New  York  City  to  investigate  this 
phase  of  the  problem,  and  it  may  be  said  in  the  first  place 
that  no  corresponding  increase  has  taken  place  in  the  death 
rate  from  the  acute  pulmonary  disease.  A  small  increase 
has  occurred  since  the  first  great  grip  epidemic  in  1890,  but 
this  increase  amounts  to  only  about  10  per  cent.,  and  is,  I 
believe,  due  to  the  influence  of  grip  in  increasing  the  death 
rate  from  the  acute  pulmonary  diseases. 

During  the  last  three  or  four  years,  at  intervals,  all  of 
the  pneumonia  deaths  have  been  compared  with  the  card 
index  of  tuberculosis  cases  reported,  to  determine  whether 
any  cases  reported  as  tuberculosis  were  subsequently 
returned  as  having  died  from  pneumonia.  This  in- 
vestigation showed  a  very  small  number  of  cases  of  this 
kind,  not  exceeding  three  or  four  a  week  in  the  Boroughs 
of  Manhattan  and  The  Bronx,  and  subsequent  investigation 
in  these,  in  the  majority  of  instances,  showed  that  a  reason- 
able doubt  existed  as  to  whether  they  were  tuberculous 
originally  or  whether  tuberculosis  was  at  all  a  factor  in  the 
causation  of  death.  In  addition  to  this,  at  intervals,  especial 
detailed  investigations  have  been  made  of  all  the  deaths  re- 
ported from  pneumonia,  occurring  in  persons  over  five  years 


29 

of  age  and  not  reported  by  large  public  institutions.  The 
latter  were  excluded  because  it  seemed  fair  to  assume  that 
the  reports  of  death  from  large  public  institutions  could  be 
relied  upon  as  accurate.  Some  hundreds  of  deaths  of  this 
sort  have  been  investigated,  to  determine  whether  the  his- 
tory of  the  disease  as  given  by  the  family  and  the  attend- 
ing physician  justified  the  assumption  that  death  was  real- 
ly due  to  tuberculosis  and  not  due  to  pneumonia.  The  re- 
sults of  these  investigations  have  again  shown  that  in  a  sur- 
prisingly small  number  of  them  was  there  any  real  reason 
for  assuming  that  tuberculosis  was  a  factor  in  the  causation 
cf  death. 

The  investigation  of  these  pneumonia  deaths  is  still  being 
continued,  and  in  all  instances,  where  the  facts  justify  the 
assumption  that  death  was  due  to  tuberculosis,  the  death 
records  are  correspondingly  changed.  As  further  investiga- 
tion has  shown  that  nearly  90  per  cent,  of  the  deaths  re- 
turned as  due  to  tuberculosis  have  been  previously  reported 
to  the  department  as  suffering  from  tuberculosis,  the  con- 
clusion seems  to  be  thoroughly  substantiated  that  the  de- 
crease in  the  deaths  from  tuberculosis  is  a  real  one  and  not 
in  any  material  respect  merely  apparent. 

I  do  not  at  all  intend  to  indicate  that  the  whole  of  the 
reduction  in  the  death  rate  from  tuberculosis  in  New  York 
City  has  been  the  result  of  the  measures  directed  especially 
against  this  disease,  for  many  other  factors  have  undoubt- 
edly contributed  to  it,  but  I  do  believe  that  the  very  great 
and  rapid  fall  in  the  tuberculous  death  rate  is  the  direct  re- 
sult of  the  application  of  these  measures ;  and  I  fully  be- 
lieve that  the  next  fifteen  years  will  see  a  reduction  nearly 
equal  to  that  which  has  already  taken  place. 

If  we  accept  at  all  the  necessary  deductions  of  our  sci- 
entific convictions  in  relation  to  tuberculosis,  there  can  be 
no  escape  from  the  conclusion  that  tuberculosis  Is  of  all  the 
important  infectious  diseases  with  which  we  have  to  deal 
certainly  the  most  preventable.  I  am  not  only  prepared  to 
accept  fully  the  deductions  from  the  known  facts  in  regard 
to  this  disease  as  to  the  possibilities  in  its  prevention,  but 
would  regard  the  experience  of  New  York  City  as  furnish- 
ing conclusive  proof  of  the  truth  of  this  conclusion. 


30 

This  is  the  great  urgent  sanitary  problem  of  the  20th 
century.  In  no  other  direction  can  such  large  results  be 
achieved  so  certainly  and  at  such  relatively  small  cost.  The 
time  is  not  far  distant  when  those  States  and  municipalities 
which  have  not  adopted  a  comprehensive  plan  for  dealing 
with  tuberculosis  will  be  regarded  as  almost  criminally  neg- 
ligent in  their  administration  of  sanitary  affairs  and  inex- 
cusably blind  to  their  own  best  economic  interests. 


COLUMBIA   UNIVERSITY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 


DATE  BORROWED 


C28I63B)ME0 


DATE   BORROWED 


RA644.T7 

B48 
1907 

1 

Biggs 

RA^Tl 

no*? 

